Online Referral Form

Note: This form is not for Emergency Transfers/Referrals. For all emergencies, please call (919) 266-9852.

rDVM Information

Type of Referral

Reason for Referral

Urgency of Referral(Required)

Referring Veterinarian

First Last

Clinic Name

Clinic Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Clinic Phone

Clinic Fax

Clinic Email

Client Information

Owner's Name

Owner's Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Owner's Phone

Owner's Email

Patient/Pet Information

Pet Name

Species

Breed

Color

Sex

DOB/Age

Weight (kgs)

Please list any behavioral concerns, allergies, or pertinent notes about the patient.

History:

Vaccine History - Please list date of last vaccine. Pets must be current on RABIES.

Rabies

Distemper

FelV

FVRCP

Diagnostics pending?

Please upload any/all of following files relating to this animal or email to [email protected].

Pet Records

Drop files here or

Max. file size: 50 MB.

Labs

Drop files here or

Max. file size: 50 MB.

Radiographs

Drop files here or

Max. file size: 50 MB.

CAPTCHA

Wake Veterinary Medical Center

1007 Tandal Place
Knightdale, NC 27545
Phone: (919) 266-9852
Fax: (919) 217-0314
Email: [email protected]

Primary Care Hours:

Monday - Friday: 7:30 a.m. - 6:00 p.m.
Saturday: 8:00 a.m. - 1:00 p.m.

EMERGENCY: OPEN 24 HOURS EVERY DAY

For after hours emergencies, please call (919) 266-9852.